[Laparoscopic total hysterectomy after radiochemotherapy in an obese woman with neuroendocrine carcinoma of the cervix: surgical and anesthesiological aspects]

Massive obesity is an important risk factor in gynaecologic surgery. The traumatic effect of traditional laparotomy on the parietal wall is responsible for important perioperative morbidity. We describe the first reported case of an obese woman (Body Mass Index = 55 kg/m2) with stage IIA neuroendocrine carcinoma of the cervix treated by laparoscopy after radiochemotherapy. After a complete response to radiochemotherapy, the patient underwent laparoscopic hysterectomy and bilateral salpingo-oophorectomy. The laparoscopic procedure was performed with a low-pressure pneumoperitoneum. She was discharged at day 2. No major complication was observed. Surgical and anesthesiological laparoscopic management in obese women are discussed.

Correlation between the treated volume, the GTV and the CTV at the time of brachytherapy and the histopathologic findings in 33 patients with operable cervix carcinoma

BACKGROUND AND PURPOSE

This study correlates the treated volume, the GTV and the CTV at the time of intracavitary brachytherapy (BT) with the histopathological findings obtained by surgery (S) in 33 patients (pts) with cervix carcinoma.

PATIENTS AND METHODS

Sixteen pts (group I), FIGO stage IB1 (1), IB2 (4), IIB (10), IIIB (1), received external beam radiotherapy (EBT) with a total dose of 45 Gy in 5 weeks and concomitant CISPLATIN 40 mg/m(2) weekly, followed by BT up to a total dose of 15 Gy. S was performed 6-8 weeks thereafter. Seventeen pts (group II), FIGO IA2 (1), IB1 (14), IIB (2), were treated by BT alone with a total dose of 60 Gy and S after 6-8 weeks. All pts had a MRI examination after BT with a moulded applicator in situ for exact delineation of GTV, CTV and critical organs and a 3D dosimetry directly from MRI data.

RESULTS

In group I (EBT + BT + S), the histopathological findings showed complete tumour sterilization (CR) in 56% of pts. Residual disease (RD) was found in 43%. Dosimetric data showed in pts with CR a larger mean treated volume (213 vs. 166 cm(3)) and a better mean coverage of the GTV and the CTV by the reference isodose (99 and 91%) as in pts with RD (85 and 77%). In group II (BT + S), CR was found in 52%, RD in 41%. Dosimetric data showed a larger mean treated volume (154 vs. 109 cm(3)) for pts with RD and a mean coverage of the GTV and the CTV by the reference isodose of 97 and 84% vs. 89 and 80% for pts with CR.

CONCLUSIONS

An incomplete coverage of the GTV and/or the CTV by the reference isodose is an important risk factor for RD at the time of surgery. Furthermore, for pts who received BT alone, tumour size seemed to be a limiting factor for an accurate coverage of the CTV by the reference isodose.

Results of Hysterectomy in Patients With Bulky Residual Disease at the End of Chemoradiotherapy for Stage IB2/II Cervical Carcinoma

BACKGROUND

We assessed the clinical outcome after hysterectomy in patients with bulky residual disease after chemoradiotherapy for stage IB2/II cervical carcinoma.

METHODS

Subjects were 10 patients who had bulky (>2 cm) residual disease in the cervix after external radiotherapy (45 Gy) combined with concomitant chemotherapy (cisplatin 40 mg/m2/week) and uterovaginal brachytherapy (15 Gy).

RESULTS

Extrafascial hysterectomy was performed in three patients, type II radical hysterectomy was performed in six patients, and pelvic exenteration was performed in one patient. Pelvic lymphadenectomy was performed in eight patients, and para-aortic lymphadenectomy was performed in eight. Five patients had nodal involvement (pelvic nodes in four and para-aortic nodes in four), and six had lymphovascular space involvement. Surgical margins were free in nine patients. Seven patients developed grade 2 (n = 3) and/or grade 3 (n = 4) complications. The median duration of follow-up after surgery was 22 months (range, 1-37 months). With follow-up available in nine patients, seven relapsed, and only two remained disease free.

CONCLUSIONS

This series confirms the high rate of nodal spread in patients with bulky residual cervical disease after chemoradiotherapy. Furthermore, patients who underwent hysterectomy had a high complication rate. Only two patients are alive and disease free. The results of surgery are disappointing; surgery does not seem to improve the survival of these patients.

Prognosis of stage III or IV primary peritoneal serous papillary carcinoma

AIMS

To study the prognosis of patients with stage IIIC/IV primary peritoneal serous papillary carcinoma (PSPC) (study group) compared with that of patients with epithelial ovarian carcinoma (EOC) (control group).

METHODS

A retrospective case-control study including a study group of 37 patients who were matched with a control group of 37 patients. Patients were matched for the histologic subtype (serous tumor), tumor stage, tumor grade, residual disease at the end of debulking surgery (initial or interval) and age (+/-5 years).

RESULTS

Debulking surgery was performed initially or at interval surgery in respectively, 10 and 27 patients in the study group and 17 and 20 in the control group. All patients were treated with platinum-based chemotherapy (combined with paclitaxel in 33) in both groups. The overall survival rate at 3 years in the study and control groups was, respectively, 60% versus 55% (NS). However, event-free survival rates at 3 years (CI 95%) were statistically different (respectively, 29% in the study group versus 16% in the control group: p=0.008).

CONCLUSIONS

Peritoneal disease is more bulky in patients with PSPC. Neoadjuvant chemotherapy is more often required to achieve optimal debulking surgery in PSPC. Overall survival of patients with PSPC is similar to that of their EOC counterparts. Thus, the management of PSPC should not be different from that of advanced stage EOC.

[Pelvic and para-aortic lymphatic involvement in tubal carcinoma: topography and surgical implications]

OBJECTIVE

The purpose of this study is to determine the topography of pelvic and para-aortic node involvement in Fallopian tube carcinoma (PFTC). This will help us to recommend appropriate surgical treatment options to the related patients.

PATIENTS AND METHOD

A retrospective study was performed on 19 women with PFTC who underwent a systematic bilateral pelvic and para-aortic lymphadenectomy.

RESULTS

The overall frequency of lymph node involvement was 47% (9/19). The frequency of pelvic and para-aortic metastases was 21% (4/19) and 42% (8/19) respectively. The frequency of lymph node metastases according to the stage of the disease (stage I, II and III) was : 29% (2/7), 50% (1/2) and 60% (6/10) respectively. The left para-aortic chain above the level of the inferior mesenteric artery was the site most frequently involved (75%) when para-aortic nodes were involved.

DISCUSSION AND CONCLUSIONS

In patients with primary tubal carcinoma, the left para-aortic chain above the level of the inferior mesenteric artery is the most frequently involved. A complete lymphadenectomy (including all pelvic and para-aortic chains up to the level of the left renal vein) should be performed in patients with primary tubal carcinoma, even in patients with stage I disease.

Detection of liver metastases from endocrine tumors: a prospective comparison of somatostatin receptor scintigraphy, computed tomography, and magnetic resonance imaging

PURPOSE

To compare the respective sensitivity of somatostatin receptor scintigraphy (SRS), computed tomography (CT), and magnetic resonance imaging (MRI) in the detection of liver metastases from well-differentiated gastroenteropancreatic endocrine tumor (WDGEP ET) patients. To define predictive factors for "high-sensitivity SRS."

PATIENTS AND METHODS

Sixty-four patients with WDGEP ET underwent SRS with abdominal single-photon emission computed tomography (SPECT), spiral CT, and 1.5-T MRI within a 15-day interval, the order of which was randomized. Two readers analyzed images of each modality, blindly and independently.

RESULTS

Hepatic metastases were present in 40 of the 64 patients and confirmed by pathology after liver biopsy or surgery in 32 and eight patients, respectively. SRS, CT, and MRI detected a total of 204, 325, and 394 metastases, respectively. The number of detected metastases was significantly higher with MRI than with CT (P = .02) and SRS (P < 10(-4)) and higher with CT than with SRS (P < 10(-4)). SRS was negative in seven patients with a positive CT and/or MRI. More lesions were detected in 10 patients by SPECT compared with static views. The median metastasis size was significantly correlated (P = .04) with the sensitivity of SRS.

CONCLUSION

MRI seems to have an edge over CT and SRS for the detection of liver metastases from endocrine tumors. We recommend the systematic performance of liver MRI at WDGEP ET initial staging and before major therapeutic events. The low performance of SRS was mainly explained by the impact of the metastasis size on the detection capacity of SRS.

Management and clinical outcomes of pregnant patients with invasive cervical cancer

BACKGROUND

The objective of this study was to evaluate the clinical outcomes and to discuss the management of women presenting with an invasive cervical cancer during pregnancy.

PATIENTS AND METHODS

We retrospectively reviewed patients treated for an invasive cervical cancer diagnosed during pregnancy between 1985 and 2000 in our institution.

RESULTS

Twenty-one pregnant patients among a total of 487 women were treated. Thirteen, five, two and one, respectively, were diagnosed during the first, second and third pregnancy trimester and post-partum. The FIGO stage was IB in 15 cases, IIB in five cases and IVA in one case. Mean follow-up was 64 months (range 2-165). Overall and disease-free survival at 5 years were 82% and 79%, respectively. All five patients diagnosed in the second trimester were alive. Two of the 13 patients and one of the two patients diagnosed during the first trimester and the third trimester, respectively, died of their disease. No difference was observed between the nine patients whose treatment was delayed or not.

CONCLUSIONS

Invasive cervical cancer during pregnancy is rare but is a dilemma for women and their physicians. The present study and review of the literature suggest that pregnancy does not seem to influence the prognosis of cervical cancer. Delayed treatment could be proposed to selected patients diagnosed at the end of the second trimester or at the beginning of the third trimester, with a small tumor (<2 cm) and negative nodes, after a multidisciplinary approach.

A need for laparoscopic evaluation of patients with endometrial carcinoma selected for conservative treatment

BACKGROUND

The aim of this paper was to report two cases of extrauterine disease in patients with early stage endometrial cancer (EC) who desired fertility-sparing management.

CASES

Two patients presenting an apparent early stage EC and desiring conservative management. The two patients, aged 35 and 36 years old, had a grade 1 and grade 2 EC diagnosed after curettage or hysteroscopic resection of a polyp. Ultrasound (US) imaging was normal (ovary). Once informed about the risk of recurrence, both patients opted for conventional therapy (hysterectomy with bilateral salpingo-oophorectomy). A small ovarian carcinoma was found in one patient and isolated positive peritoneal cytology in the other.

CONCLUSIONS

These cases seem to suggest that laparoscopic evaluation including adnexal exploration and peritoneal cytology (and possibly pelvic lymphadenectomy) should be performed in patients with early stage EC selected for conservative management to confirm the absence of extrauterine disease.

Anatomy of pelvic and para-aortic nodal spread in patients with primary fallopian tube carcinoma

BACKGROUND

To describe characteristics of patients with nodal spread and the anatomy of pelvic and para-aortic node involvement in primary fallopian tube carcinoma.

STUDY DESIGN

Between 1985 and 2003, 19 women with primary fallopian tube carcinoma underwent systematic bilateral pelvic and para-aortic lymphadenectomy up to the level of the left renal vein. Initial lymphadenectomy (without chemotherapy) was performed in 6 patients and in 13 patients lymphadenectomies were performed after chemotherapy at the time of second-look operation.

RESULTS

Nine patients had nodal involvement: four in the pelvic area and eight in the para-aortic nodes. Two, one, and six patients had stages I, II, or III disease, respectively. When para-aortic nodes were involved, the left para-aortic chain above the level of the inferior mesenteric artery was the site most frequently involved (six patients).

CONCLUSIONS

In patients with primary tubal carcinoma, the left para-aortic chain above the level of the inferior mesenteric artery is the most frequently involved. Lymphadenectomy should involve all pelvic and para-aortic chains up to the level of the left renal vein, even in patients with stage I disease.

[Place and results of frozen section analysis in the management of malignant and borderline ovarian tumors]

The management of ovarian tumors discovered during laparoscopy depends equally on the surgeon and the pathologist. Thus, the surgeon will undergo a more or less radical surgery depending on frozen section analysis (FSA),which depends mainly on the pathologist's skills, the histopathologic type and the volume and the localization of the tumor. The accuracy of FSA is higher in ovarian cancer than in borderline tumor. In patients treated initially with a laparoscopic approach, if the FSA demonstrates the presence of an invasive carcinoma, a conversion to laparotomy should be performed in order to complete the surgical staging. If the FSA demonstrates the presence of a borderline tumor, an exclusive laparoscopic approach could be discussed.

An appendix carcinoid tumor in a patient with hereditary nonpolyposis colorectal cancer

Gastrointestinal carcinoid tumors are often associated with other tumors, particularly colon adenocarcinomas; but the association between carcinoid tumors and hereditary nonpolyposis colorectal cancer (HNPCC) syndrome has not yet been explored. We report an unusual case of a 28-year-old woman with HNPCC who underwent surgery for a transverse colon adenocarcinoma in whom an appendix carcinoid tumor was incidentally found. To assess whether the carcinoid tumor displayed the characteristic molecular features of HNPCC tumors, we investigated the expression of mismatch-repair (MMR) proteins and microsatellite instability (MSI) status in both tumors. Both tumors demonstrated normal expression of the MMR proteins hMLH1, hMSH2, hMSH6, and hPMS2. Interestingly, the adenocarcinoma exhibited an MSI phenotype but the carcinoid tumor did not, indicating that these 2 tumors arose through different molecular pathways.

Port-Site Implantation After Laparoscopic Treatment of Borderline Ovarian Tumors

BACKGROUND

The aim of this article is to report 3 cases of port-site implantation after laparoscopic treatment of a borderline ovarian tumor.

CASES

Three patients underwent a laparoscopic procedure for a serous (2 patients) or mucinous (1 patient) borderline ovarian tumor. In 2 patients, the port-site implantation was discovered during a later surgical procedure, and one was discovered clinically 11 months after the initial laparoscopic oophorectomy. Surgical resection of the port-site was the only treatment in all cases. These women are currently alive and disease-free 11, 23, and 51 months after the treatment of the scar metastasis.

CONCLUSIONS

These results suggest that, unlike port-site metastasis in other gynecologic malignancies, the prognosis in patients with a port-site implantation after laparoscopic management of borderline ovarian tumor is excellent. The treatment of this complication is surgical resection.

Adjuvant chemotherapy with cisplatin, ifosfamide, and doxorubicin followed by radiotherapy in localized uterine sarcomas: results of a case-control study with radiotherapy alone

Uterine sarcoma is a poor prognosis disease, with a high risk of metastatic relapse. We conducted a study of adjuvant chemotherapy with cisplatin, ifosfamide, and doxorubicin followed by radiotherapy (n=18). The results were then compared in a matched case-controlled study to radiotherapy alone (n=16) or no therapy at all (n=2). Chemotherapy consisted in three cycles of adriamyein-platinum-ifosfamide (API) (doxorubicin 60 mg /m2 on day 1; cisplatin 100 mg /m2 on day 2; ifosfamide 5 g /m2 on day 1+mesna 5 g /m2 on day 1+granulocyte colony-stimulating factor; q 3 weeks). Drug doses were reduced (20% for ifosfamide and cisplatin) four times (four patients) due to hematologic toxicity. Compared to a case-control study of adjuvant radiotherapy alone, results were not decreased by the addition of a toxic chemotherapy.

CONCLUSION

Adjuvant API chemotherapy followed by radiotherapy is a feasible protocol; a multicenter phase III study comparing radiotherapy alone versus API chemotherapy followed by radiotherapy just began in France.

[Management of advanced stage ovarian cancer]

The management of advanced stage ovarian cancer was deeply modified during last years. The standard treatment of advanced stage ovarian cancer in 2004 remains the initial surgery (in order to obtain ideally a total resection of all macroscopic disease) followed by adjuvant chemotherapy (6 courses of platinum based chemotherapy). But in patients with massive spread, interval debulking surgery (performed after 3 or 4 courses of neo-adjuvant chemotherapy) is becoming an interesting option (and perhaps will become a standard management). This treatment is actually studied in randomized trials.

Malignant female adnexal tumor of probable wolffian origin relapsing after pregnancy

BACKGROUND

Female adnexal tumors of probable wolffian origin (FATWO) represent a rare gynecologic tumor and display in the majority of cases a benign behavior.

CASE

A 27-year-old woman underwent a laparotomy for a left adnexal mass. Pathologic examination showed a FATWO. Three years later, 1 month after a vaginal delivery, a recurrence of the disease was observed. Immunohistochemistry revealed the presence of progesterone receptors that may explain recurrence after pregnancy.

CONCLUSION

In light of this case, hormone dependency of FATWO may be suggested.

Surgical management of primary anorectal melanoma

BACKGROUND

This aim of this study was to analyse outcome after surgery for primary anorectal melanoma and to determine factors predictive of survival.

METHODS

Records of 40 patients treated between 1977 and 2002 were reviewed.

RESULTS

Twelve men and 28 women of mean age 58.1 (range 37-83) years were included in the analysis. Overall and disease-free survival rates were 17 and 14 per cent at 5 years. Median overall survival was 17 months and disease-free survival was 10 months. The 5-year survival rate was 24 per cent for patients with stage I tumours, and zero for those with stage II or stage III disease. There was no significant difference in overall survival after wide local excision (49 and 16 per cent at 2 and 5 years respectively) and abdominoperineal resection (33 per cent at both time points). In patients with stage I and stage II disease, there was a significant association between poor survival and duration of symptoms (more than 3 months), inguinal lymph node involvement, tumour stage and presence of amelanotic melanoma.

CONCLUSION

Anorectal melanoma is a rare disease with a poor prognosis. Wide local excision is recommended as primary therapy if negative resection margins can be achieved.

Contralateral groin recurrence in patients with stage I Bartholin's gland squamous cell carcinoma and negative ipsilateral nodes: report on two cases and implications for lymphadenectomy

BACKGROUND

Modalities of inguinal lymphadenectomy in patients with early stage Bartholin's gland squamous cell carcinoma (BGC) remain discussed. The aim of this paper is to report 2 patients with stage 1 BGC and negative ipsilateral groin nodes who developed a contralateral groin recurrence.

CASES

Two patients treated for BGC and undergoing an ipsilateral groin nodes dissection (with absence of nodal involvement) presented contralateral groin recurrence. These recurrences were observed 14 and 3 months after the initial treatment in the first and second case. In the first case, the nodal recurrence was associated with a local vaginal recurrence.

CONCLUSIONS

These 2 cases suggest that << cross >> groin nodal involvement can occur, even in patients with early stage BGC. Bilateral groin dissection should be performed in patients with BGC.

Impact of surgical staging in patients with macroscopic “stage I” ovarian borderline tumours: analysis of a continuous series of 101 cases

The aim of this study was to assess the patient's clinical outcome following complete or incomplete surgical staging in cases treated for an early stage low-malignant-potential ovarian tumour (LMPOT). One-hundred and one patients treated between 1965 and 1998 for a early stage I LMPOT were reviewed according to whether the initial surgical staging was complete (Group 1/defined by peritoneal cytology + peritoneal biopsies + infracolic omentectomy) or incomplete (Group 2/omission of at least one of the peritoneal staging procedures described above). Complete and incomplete surgical stagings were carried out in 48 (48%) and 53 (52%) patients, respectively. Four (8%) LMPOT recurrences were observed in Group 2, all following conservative management, but there were no recurrences in Group 1. No relapses with invasive carcinoma or peritoneal disease and no tumour-related deaths were observed. The absence of complete peritoneal staging in patients with an apparent "stage I" LMPOT increased the recurrence rate. However, this surgical restaging (in cases of incomplete initial surgery) does not modify the survival of patients with apparent "stage I" LMPOT misdiagnosed during the initial surgery. This procedure could probably be omitted: (1) if the peritoneum is clearly reported as "normal" during the initial surgery; (2) in the absence of a micropapillary pattern; and (3) if the patient agrees to be carefully followed-up.

[Clinical practice guidelines: Standards, Options and Recommendations for first line medical treatment of patients with ovarian neoplasms (summary report)]

CONTEXT

The "Standards, Options and Recommendations" (SOR) project, which started in 1993, is a collaboration between the French Federation of Cancer Centers (FNCLCC), the 20 French Regional Cancer Centers, and specialists from French public universities, general hospitals and private clinics. The main objective is the development of clinical practice guidelines to improve the quality of health care and the outcome of cancer patients.

OBJECTIVE

To update clinical practice guidelines for first line medical treatment of patients with ovarian neoplasms in collaboration with the French Society for Gynaecologica Oncology.

METHODS

The methodology is based on a literature review and critical appraisal by a multidisciplinary group of experts. The CPGs are defined following the definitions of the Standards, Options and Recommendations project. Once the guideline has been developed, the document is submitted for review by independent reviewers.

RESULTS

This article is a summary version of the full document presenting the clinical practice guidelines with algorithms. After surgery, most patients with ovarian neoplasms need adjuvant medical treatment. These guidelines concern the initial medical treatment (chemotherapy, hormone treatment and immunotherapy) and potential consolidation treatment. To complete the indications, two alternative treatment strategies are taken into account: no treatment and radiotherapy. This updated version concerns the indications and the modalities of chemotherapy. The main modifications are: 1) first-line chemotherapy for ovarian neoplasm can be taxane-platinum or carboplatine alone; 2) poly-chemotherapy is no longer a standard; 3) for early stages, except for stage IA grade I non-clear-cell tumours, adjuvant chemotherapy should be preferred to no treatment; 4) chemotherapy is standard for all stage III tumours, irrespective of the surgical result; 5) for stage IA G2-3 to IIA tumours, complete surgical staging and determination of the histological grade are standards.

Outcomes After Combined Therapy Including Surgical Resection in Patients with Epithelial Ovarian Cancer Recurrence(s) Exclusively in Lymph Nodes

BACKGROUND

The aim was to study the prognosis for and survival of patients treated with combined therapy (including surgical resection) for nodal recurrences from epithelial ovarian cancer (EOC).

METHODS

This was a retrospective study of a group of 12 patients with a recurrence from EOC, a priori, exclusively located in lymph node(s). All patients underwent surgical resection of nodal metastases, followed by adjuvant therapy.

RESULTS

The median age of patients was 51 (range, 42-71) years. The initial disease stages were as follows: stage IA, n = 5; stage IIA, n = 1; and stage IIIC, n = 6. The median interval between the end of initial treatment and the nodal relapse was 21 (range, 6-72) months. The recurrence was located in the abdominal nodes in 10 patients (pelvic and/or para-aortic area) and was extra-pelvic in one patient, and the last patient had concomitant para-aortic and supraclavicular nodal involvement. Ten patients received postoperative chemotherapy and two had radiation therapy (one patient received both treatments). Eight patients relapsed and four did not. To date, three patients have died of the disease, three are alive with persistent disease, and six are alive and disease-free (including two patients who were treated by surgical resection after relapses twice in abdominal nodes). Five-year overall survival from the time of treatment of recurrent disease is 71% (confidence interval, 41%-90%).

CONCLUSIONS

The prognosis of patients with an a priori isolated nodal recurrence from EOC was good in this group of treated with surgical resection followed by chemoradiation or radiation therapy. This finding argues in favor of proposing surgical resection in such patients.

Les métastases ganglionnaires du cancer épithélial de l'ovaire sont-elles chimio-sensibles ? Étude comparative de la lymphadénectomie première ou après chimiothérapie

OBJECTIVE

The aim of this study is to compare the rates of nodal involvement in epithelial ovarian cancer (EOC) in patients who underwent initial lymphadenectomy (before chemotherapy/group 1) and patients who underwent lymphadenectomy after chemotherapy (during interval debulking surgery/group 2 or second-look surgery/group 3).

PATIENTS AND METHODS

The rates of nodal involvement in 205 patients with EOC who underwent complete pelvic and paraaortic lympadenectomy were compared. One hundred and five patients underwent this surgical procedure at the end of chemotherapy (group 3) or during chemotherapy (group 2) for 28 patients (with three courses of a platinum-based regimen containing paclitaxel) and were compared to 100 patients who underwent initial lymphadenectomy (group 1).

RESULTS

In patients with stage I and II disease the rate of nodal involvement in group 1 and 3 were similar (respectively 19% vs. 21% and 50% vs. 33% in stage I or II disease-NS). In patients with stage III disease, the rates of nodal involvement in patients treated with initial surgery, interval debulking surgery (with paclitaxel-based regimen) and second-look surgery were respectively: 53%, 58% and 48% (NS). Adding to the platinum-based regimen does not seem to improve node sterilization rates.

DISCUSSION AND CONCLUSIONS

The rates of nodal involvement seem to be similar in patients treated before or after chemotherapy but the comparison of groups is difficult because the presence of several bias (particularly in early stage disease). Such results suggest that nodal metastases are not totally sterilized by chemotherapy. However, further studies are needed to evaluate the therapeutic value of lymphadenectomy in patients with nodal involvement.